Inquest Records Verdict Of Medical Misadventure

A medical law expert says the NHS must learn from its mistakes and act on concerns raised by a coroner after a newborn baby died following an avoidable delay in his delivery at Stepping Hill hospital. The coroner will now be writing to the Secretary of State to share his advice to consultants.

Harley Hikin-Balderson was just 36 minutes old when he died as a result of a deprivation of oxygen on 11 September 2009.

At an inquest which concluded at Stockport Coroner’s Court today (19 January 2011), Coroner John Pollard returned a verdict of medical misadventure, and highlighted errors made by the hospital.

He also revealed his intention to write to the Secretary of State, to advise that consultant doctors across the country are given clear guidance on the advice they provide to junior doctors over the telephone.

The inquest heard that foetal blood samples showed Harley’s condition was deteriorating and he should have been delivered as an emergency. Instead, medical staff attempted to deliver Harley using suction and forceps causing a delay. The caesarean section was finally carried out two hours after the blood sample revealed abnormalities.

Medical law specialists at Irwin Mitchell, who represented Harley’s family at inquest, are now calling for the NHS to ensure lessons are learnt to stop other families from suffering in the future. 

Leena Savjani, a medical law expert at Irwin Mitchell, said: “The delay in delivering Harley put his family through a tragic ordeal, and his parents are naturally heartbroken. They just want to know what went wrong in their case and why, so that they can be assured that no one else has to go through what they have.

“This case highlights how just one error in judgement can have such an impact and effect on a family forever. It is crucial that the NHS learns important lessons from its failings in this case to ensure this can not happen again in the future.

“We see these cases time and time again. Tragically, Harley’s is not the only example of poor obstetric care leading to injury and as in this case, death and utter anguish for the parents.

“This is an area that needs urgent attention from the NHS as it clearly shows the capacity for serious error with junior doctors and flags a training need that can not be ignored any more. The guidance to consultants must be improved quickly and we welcome the coroner’s plans to write to the Secretary of State and hope it prompts quick action.”

During the inquest the consultant, Dr Depares, testified that the “delay in delivering Harley significantly contributed to his death”, and that Harley may well have survived if had he been born even 30 minutes earlier. 

Dr Depares also added that had he had been on the ward in the lead up to the birth, “Harley would probably still be alive.”

In summing up before his verdict Mr Pollard said there was no clear lead provided in managing this delivery.” He now plans to write to the CEO of Stepping Hill Hospital to express his concerns and offer guidance on improvements.

Harley’s mother, Kirsty Hikin, 23, from Stockport, said: “The past 16 months have been horrendous. For so long we had been looking forward to Harley’s birth and couldn’t wait to bring him home, but tragically we never got that opportunity. His death has left a massive void in our lives that has left us devastated.

“The inquest has helped to answer some of our questions as to why Harley died but sadly nothing can ever be done to bring him back.

“We only hope that the hospital learns from its mistakes so that nobody else has to go through the horrible situation what we have over the past year.”

PLEASE NOTE: THE FAMILY HAVE REQUESTED THAT ALL MEDIA ENQUIRIES AND INTERVIEW REQUESTS ARE DIRECTED THROUGH THE IRWIN MITCHELL PRESS OFFICE.